Oncology: Oncology I: Overview & Side Effect Management Flashcards
Neoadjuvant therapy is given…
before primary treatment to shrink size
Adjuvant therapy is given…
after primary therapy or with other therapy to get rid of remaining disease and decrease recurrence
Warning signs of cancer
C = change in bowel/bladder habits
A = sore that doesnt heal
U = unusual bleeding or discharge
T = thickening or lump in breast or elsewhere
I = indigestion or difficulty swallowing
O = obvious change in wart or mole
N = nagging cough or hoarseness
Breast cancer screening
40-44 = annual mammogram optional
45-54 = yearly mammogram
55 + = mammograms Q 2 yrs or yearly
Cervical cancer screening
25-65 yrs old
Pap smear every 3 yrs
HPA DNA test every 5 years
Pap smear + HPV test every 5 yrs
Colorectal stool based screening
> 45 yrs old
if positive, get a colonoscopy
FIT test yearly
gFOBT yearly
stool DNA test every 3 years
Colorectal visual based screening
> 45 yrs old
Colonoscopy every 10 yrs
CT colonography every 5 years
Flexible sigmoidoscopy every 5 yrs
Lung cancer screening
> 50 yrs old
annual CT of chest if….
- 20 pack/yr smoking history
- still smoking or quit last 15 yrs
Prostate cancer screening
if choose to get tested…
PSA
Digital rectal exam
Lifetime cumulative dose of Bleomycin
400 units
Pulmonary toxicity
Lifetime cumulative dose of Doxorubicin
450-550mg/m2
cardio toxicity
Lifetime cumulative dose of Cisplatin
no more than 100mg/m2 per cycle
Nephrotoxicity
Lifetime cumulative dose of Vincristine
single dose capped at 2mg
Neuropathy
Common drugs that cause Myelosuppression
Most chemo agents besides…..
- asparaginase
- bleomycin
- vincristine
- most monoclonal antibodies
Common drugs that cause nausea and vomiting
Cisplatin
cyclophosphamide
ifosfamide
doxorubicin
epirubicin
Common drugs that cause mucositis
fluorouracil
methotrexate
capecitabine
irinotecan
many TKIs
Common drugs that cause diarrhea
Irinotecan
capecitabine
fluorouracil
methotrexate
many TKIs
Common drugs that cause Constipation
Vincristine
pomalidomide
thalidomide
Common drugs that cause Xerostomia (dry mouth)
radiation to head or neck regions
Common medications that cause Cardiomyopathy
Anthracyclines
HER2 inhibitors
fluorouracil
Common medications that cause QT prolongation
Arsenic trioxide
many TKIs
Leuprolide
Common medications that cause Pulmonary fibrosis
Bleomycin
busulfan
carmustine
lomustine
Common medications that cause Pneumonitis
Methotrexate
MAbs targeting CTLA-4 or PD-1/PD-L1
Common medications that cause hepatotoxicity
Antiandrogens (bicalutamide, flutamide, nilutamide)
methotrexate
cytrabien
Many TKIs
some MAbs
Common medications that cause Nephrotoxicity
Cisplatin
High dose Methotrexate
Common medications that cause Hemorrhagic Cystitis
Ifosfamide = all doses
cyclophosphamide = high dose > 1g/m2
Common medications that cause Peripheral Neuropathy
Vinca alkaloids
Platinums
Taxanes
Proteasome inhibitors
Common medications that cause Autonomic Neuropathy
Vinca Alkaloids
Common medications that cause Thromboembolic risk
Aromatase inhibitors (anastrozole, letrozole)
SERMs
immunomodulators (thalidomide, lenalidomide, pomalidomide)
What should be avoided with Oxaliplatin
avoid cold temperatures and avoid drinking cold beverages
What is myelosuppression
dec in bone marrow activity
results in fever RBCs, WBCs, and platelets
complication of most chemo therapy
Lowest point that WBCs and platelets can reach is called…
nadir
usually within 7-14 days after chemo
for RBC, nadir is ~ 120 days
Drugs used to inc RBC count
ESA = Erythropoiesis-stimulating agent
Epoetin alfa (Epogen, Procrit)
Darbepoetin alfa (Aranesp)
Drugs used to inc WBC count
Colony-stimulating factor (CSF)
Filgrastim (Neupogen)
Pegfilgrastim (Neulasta)
Categories of Neutropenia and ANC
Neutropenia = < 1,000
Severe Neutropenia = < 500
Profound Neutropenia = < 100
Who should receive CSF when getting chemo?
all patients with > 20% chance of developing chemotherapy induced febrile neutropenia
CSF side effects
bone pain, fever, general rash, injection site reaction
CSF notes
store in fridge
give 1st dose no sooner than 24hrs after chemo, can be up to 96hrs after
report signs of enlarged spleen
Pegfilgrastim: given atleast 14 days before next chemo cycle
Febrile neutropenia diagnosis requirements
Temp > 38.3C (101F) X 1 or > 38C (100.4F) for 1hr & ANC < 500 or ANC < 1000 expected to be < 500 next 48hrs
Empiric febrile neutropenia abx for low risk patients
Low risk = ANC < 100 for < 7 days
Cipro/Levo + Amox/clav or clinda
Empiric febrile neutropenia abx for high risk patients
High risk = ANC < 100 for > 7 days, comorbidities, CrCl < 30
Cefepime or Ceftazdime or Meropenem or Impinge/cilastatin or pip/tazo
Why are ESA not recommended in patients receiving chemo with curative intent?
can shorten survival and inc tumor progression
only used for palliative care in chemo
What would be assessed before doing ESA?
Serum ferritin
TSAT
TIBC
Threshold for platelet transfusion
<10K
< 30k if active bleeding
3 types of Chemotherapy induced nausea and vomiting
Acute = within 24hrs of chemo
Delayed = > 24 hrs after chemo
Anticipatory = before chemo
Antiemetic regimen for minimal emetic risk drugs
no routine prophylaxis
Antiemetic regimen for low emetic risk drugs
1 of the following
5HT3-RA ( -setrons), Dexamethasone, prochloprperazine, metoclopramide
Antiemetic regimen for moderate emetic risk drugs
2 - 3 drugs
5HT3-RA + NK1-RA + dexamthasone
5HT3-RA + dexamethasone
Palonosetron + Olanzapine + dexamethasone
NK1-RA drugs
Aprepitant
Aprepitant IV
Fosaprepitant IV
Rolapitant
Antiemetic regimen for high emetic risk drugs
3 or 4 drugs
NK1-RA + 5HT3-RA + olanzapine + dexamethasone = preferred
Palonosetron + olanzapine + dexamethasone
NK1-RA + 5HT3-RA + dexamethasone
NK1-RA drug notes
can dec dexamethasone dose when used with these drugs
dont dec dexamethasone dose when used with Rolapitant
Granisetron patch notes
start 24-48hrs before chemo
leave in place for up to 7 days
5HT3-RA medication contraindications
Dont use with apomorphine (Awoken) due to severe hypotension and loss of consiousness
5HT3-RA medication warnings
inc QT interval, Torsades
limit IV to 16mg
SErotonin syndrome when used in combo with serotonergic agents
5HT3-RA medication side effects
headache
constipation
fatigue
dizziness
inj site reactions
Dexamethasone (Decadron) used for CINV
Off label
Side effects: inc appetite, weight gain, fluid retention, insomnia
higher doses can inc BP and BG in diabetes patients
Dopamin receptor antagonists for CINV
Prochlorperazine (Compazine)
Promethazine (Phenergan)
Metoclopramide (Reglan)
Olanzapine (Zyprexa)
Haloperidol (Haldol)
Prochlorperazine boxed warnings
inc mortality in elderly with dementia related psychosis
Promethazine Boxed warnings
dont use children < 2 yrs old
Dont give via SC, Deep IM preferred due to extravasation with IV
Metocloramide Boxed warnings
Tardive dyskinesia that can be irreversible, D/c if symptoms occur
dont treat more than 12 wks
dec dose with renal impairment
Haldol/Droperidol Boxed warnings
QT prolongation and serious arrhythmia
Dopamine receptor antagonists warnings
symptoms of Parkinson’s maybe exacerbated, avoid in patients with disease
Dopamine receptor antagonist side effects
Sedation
lethargy
acute EPS
dec seizure threshold
QT prolongation
NMS
hypotension
Olanzapine side effects for CINV
mild sedation and orthostasis when used for CINV
Dronabinol (Marinol) info
SE: somnolence, euphoria, inc appetite
Keep in fridge**
Meds used for anticipatory N/V
Lorazepam, start evening before
Chemo agents that commonly cause diarrhea
Fluorouracil
Capecitabine
Irinotecan
occurs several days after chemo
Early onset diarrhea
Irinotecan cause cause it, occurs during infusion
also causes symptoms of cholinergic excess
Cholinergic excess symptoms
cramping
rhinitis
lacrimation
salivation
Hand-foot syndrome commonly occurs with
capecitabine
fluorouracil
cytarabine
liposomal doxorubicin
TKIs = sorafenib and sunitinib
symptoms of Hand-foot syndrome
tenderness
pain
inflammation
maybe peeling of palms and soles
Hand-foot syndrome management
avoid pressure on sole and palms of hands
avoid prolonged exposure to hot water
avoid activities that cause friction or heat exposure to hands/feet
Tumor lysis syndrome occurs most commonly with which cancers
Leukemia and non-Hodgkin Lymphoma
but can occur with most cancer types
Meds used to treat TLS
Allopurinol at 400-800mg/day until normalization
Tumor Lysis syndrome can cause
acute hyperkalemia = arrythmias
hyperphosphatemia/hypercalcemia = anorexia, nausea, seizures)
hyperuricemia
Hypercalcemia of malignancy
some cancers cause calcium to leach from bone to blood, leading to hypercalcemia
Txm of moderate to severe hypercalcemia
Corrected calcium form 12-13.9 to > 14
Iv bisphosphonates = 1st line
calcitonin can be added, but short txm duration due to tachyphylaxsis w/ calcitonin
Can also use Denosumab (Xgeva)
IV Bisphosphonates + Denosumab Dose
Bisphosphonates = 4mg IV once, can repeat in 7 days if needed
Denosumab = 120mg SC days 1,8,15 of 1st month, then every month
Premedication to prevent immunologic reactions from MAbs
Tylenol
Benadryl or another antihistamine
Major chemo vesicants
Anthracyclines
vinca alkaloids
Antidote for Anthracycline extravasation
dexrazoxane or dimethyl sulfoxide
Antidote for vinyl alkaloid/etoposide extravasation
hyaluronidase
When should vaccines be given if receiving chemo therapy?
> 2 weeks prior
